Nursing Diagnosis

MATERNAL CHILD NURSING CARE 5TH EDITION BY
PERRY
HOCKENBERRY
LOWERDERMILK
WILSON
Chapter 3,4 &8
Answer the following case study questions there are three:
(1) Self-examination of the breasts and vulva (genitalia) are important assessment
techniques to teach a woman. Ellen is a 24 year old African-American client who is in the
clinic for yearly health examination. She asks for a nurse to teach her about self-
examination of her breasts. “I feel like I should know this especially since I have a friend
who has breast cancer.”
Describe assessment of readiness for teaching this client
(1)Readiness
(2) Motivation
(3) Current status (age intellectual level and/or educational (reading) level, cultural
background, etc). What does the evidence say about this group and their teaching needs
(4 ) Interest and actual and/or potential barriers to learning
( 5) Environment
(6) Identify outcomes of teaching.
(7) Outline the procedure that you would use to teach the technique to one of your patients.
(8) Include the teaching methodologies that you would use to enhance learning.
(9) List evaluative criteria. (How would you know the patient has learned?)

  1. Martha is 4 weeks pregnant. As part of her prenatal assessment, it is discovered that she
    is HIV positive. Identify measures that can be used to reduce the risk of transmission of
    HIV from Martha to her baby.
  2. Write one nursing diagnosis for the following situation, one expected outcome, and two
    nursing measures for the nursing diagnosis you identified.
    Beth is 6 weeks pregnant. During the health history interview, she tells you that she has
    limited her intake of fluids and tries to hold her urine as long as she can because, “I just
    hate having to go to the bathroom so frequently.”

Nursing Diagnosis, Assessments, and Measures
Assessing the readiness to teach a client

Readiness; Ellen is ready to learn since she personally requests if she could be taught how to
perform the examination. Moreover, she is conscious that her friend has breast cancer and wants
to know what can be done to avoid it.

NURSING DIAGNOSIS, ASSESSMENTS, AND MEASURES 2
Motivation; Ellen is motivated by the fact that she does not want to end up a victim of breast
cancer. She can also use the information to educate other ladies who are close to her.
Current status; breast cancer is prevalent among the African-Americans. Her age is a proof that
her education and intellectual level permit her to be informed about the information she seeks.
Her group is conscious about their beauty and health care and, therefore, the curiosity will enable
her to grasp the information faster (Perry et al., 2014).
Interest and potential barriers; since Ellen is young and could be engaging in various
activities, there is a likelihood that she might forget the information or lack the time to conduct
the test. There might be worry and fear that she will notice a lump (Perry et al., 2014).
Environment; the nurse is the most appropriate person to teach Ellen and they should be in an
private room so that the nurse can begin by assessing Ellen and can allow her to demonstrate the
examination after the lesson.
Outcomes; exposing the young lady to information of BSE will place her in a better position to
take good care of herself and teach others in a way that they are satisfied.
Procedure; the test should be conducted 3-5 days after beginning the menstrual cycle (Perry et
al., 2014). Lie on the back, place the right hand behind the head and with the middle left hand’s
fingers, firmly yet gently press down using minute motions and examine the whole right breast.
Then stand and examine the armpit. Squeeze the nipple gently and check for any discharge. The
process should be repeated on the left breast. Then any skin texture changes should be examined,
and the outline and shape of breasts noted.
Methodologies to enhance learning; there can be provision of updated and effective
audiovisual aids such as (BEFD) Breast Examination Facilitation Device with various breast
sizes, instructional self-explanatory materials, and overhead projectors (Perry et al., 2014).

NURSING DIAGNOSIS, ASSESSMENTS, AND MEASURES 3
Evaluative criteria; Ellen should be able to demonstrate the examination effectively and recall
all the relevant information.

Measures for reducing the risk of transmitting HIV to a baby
Martha has the option of joining the PMTCT programme, which is offered on a free of
charge basis. A WHO staging and CD4 count is necessary for Martha before she begins ARV
(Antiretroviral Treatment) (Perry et al., 2014). The ARVs will minimize the risk of transmitting
HIV to the baby as well as protecting the health of the mother after and during pregnancy. ARVs
should be begun within seven days after diagnosis. Martha should be followed up closely during
her entire pregnancy and advised on how to feed well. During labor, she should take the ARVs to
the labor ward and should not cease taking them. After discharge, the baby should be given
Nevirapine syrup within 6- 72 hours. The baby should also be given Nevirapine syrup further for
4-12 weeks depending on the length of time the mother has been on the ARVs (Perry et al.,
2014).

Frequent urination during pregnancy

Actually, the frequent urination is as a result of pregnancy. There is increased blood flow
and the extra blood results to the extra fluids being processed via the kidneys into the bladder.
Limiting fluid intake causes dehydration, which is detrimental to the mother and the baby.
Trying to hold urine leads to urinary tract and bladder infections, which are critical for pregnant
women. Urinating helps in getting toxins out of the body and if urine is held, toxins are retained
in the urinary tract and bladder, which increases chances for infection (Perry et al., 2014). Beth
can be advised to lean forward when urinating so that the bladder is emptied completely. Drinks
with a diuretic effect should be avoided as they cause more frequent urination.

NURSING DIAGNOSIS, ASSESSMENTS, AND MEASURES 4

Reference

Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L. & Wilson, D. (2014). Maternal Child
Nursing Care (5th Ed.). New York: Elsevier Inc.

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